Tobacco Control has morphed into a crusade intent on demonizing both tobacco users and the industry supplying them. This blog examines and comments on scientific issues surrounding tobacco policies - and fallacies.

Wednesday, October 26, 2011

A study published in Harm Reduction Journal (here) concludes that there is “an untapped interest in the use of substitutes to reduce the harmfulness of smoking…The greater the range of products on offer, the more smokers are likely to try a product to quit.”

The study’s lead author is Ron Borland at Australia’s VicHealth Center for Tobacco Control. His coauthors are from the University of Nottingham in the UK, and Roswell Park Cancer Institute in Buffalo, New York.

Thirty-four smokers in the UK and 31 in Australia were recruited; each received a variety of smoke-free substitutes for “short term use (less than 1 week).” In the UK, 15 smokers preferred nicotine lozenges, 9 preferred Oliver Twist (here), one liked both products and 8 liked neither. Smokers in Australia were sent more products, and 17 tried all of them. Six favored Oliver Twist, 5 liked nicotine lozenges, 2 preferred Swedish snus (here) and one favored Stonewall/Ariva dissolvables (here); three smokers didn’t like any of the smoke-free alternatives.

Borland and colleagues reported that there was “considerable interest in using [pharmaceutical nicotine and smokeless tobacco] as a means of quitting smoking or as a long-term substitute for smoking.” They added that “the greater range of options provided, the more likely we are to find one that will be acceptable to any given smoker, thus increasing the potential pool of those who might be helped” and they advocated sampling to get “the participant to choose the product they wanted to use longer term” as a “sensible and viable approach for encouraging more than minimal use of substitute products.”

The authors reasonably write that smokers should try a variety of smoke-free substitutes, but they add an unrealistic caveat -- “we should not allow for-profit companies to directly market them to consumers, rather they should be available from a not-for-profit source.”

Borland and colleagues conclude that “…many smokers are interested in reducing the harmfulness of their smoking behaviour. Smokers deserve to know what the differential risks of potential alternatives are, and to be supported to make the choices that are in their long-term best interests, which is to quit nicotine altogether, but failing that use the least harmful form of nicotine they find acceptable.”

Many smokers are interested in harm reduction, but too many are dying every year – 15,000 in Australia, 80,000 in the UK and 400,000 in the US – because they don’t have truthful information about vastly safer cigarette alternatives.

Wednesday, October 19, 2011

The New England Journal of Medicine on September 29 published a commentary (here) promoting “total abstinence” with behavioral therapy and medicines, a strategy that has failed to help over 90% of smokers who tried to quit. The article, by Michael Fiore and Timothy Baker of the University of Wisconsin, reflects the nation’s dual obsession with smoking as a disease and nicotine- and tobacco-abstinence as the only cure.

Fiore and Baker use the terms “smoking” and “tobacco use” synonymously. They write, “more than 30% of deaths from cancer, 90% of cases of COPD and 30% of cases of cardiovascular disease in the United States are attributed to tobacco use…Tobacco use remains the chief avoidable cause of death in the United States…”

That is demonstrably false. Tellingly, in the next sentence they drop the phrase “tobacco use” and correctly use the word “smoking.” I have previously described the unfortunate consequences of such deliberate misinformation (here).

While Fiore and Baker advise health professionals to “note the effectiveness of seven FDA-approved medications for smoking cessation,” they acknowledge that a meta-analysis documented that the abstinence rate for nicotine medicines was a mere 9% at six months -- a 91% failure rate. Despite these dismal statistics, Fiore and Baker use the words “effective” or “effectiveness” at least 10 times in describing quit-smoking medicines. Interestingly, they write that patients don’t use medicines because they believe them to be “dangerous” and “ineffective.” Although smokers incorrectly believe that nicotine medicines are dangerous, they are correct in believing that they are largely ineffective.

Anti-tobacco extremists and most journal editors continue to ignore the scientific evidence for tobacco harm reduction, but some medical journals are putting it front and center (here). It is unfortunate that the New England Journal of Medicine devoted 10 pages to a misleading abstinence-only screed.

Tuesday, October 11, 2011

The World Anti-Doping Agency (WADA), an international agency composed and funded by sport organizations and governments, on September 27 announced it will “monitor the effects nicotine can have on performance when taken in oral tobacco products such as snus,” starting in 2012 (here). This followed publication of a report from the agency’s laboratory on over 2,000 urine samples from athletes in 43 sports. The report, by François Marclay and colleagues at the University of Lausanne in Switzerland, is abstracted here.

The research measured exposure to and active use of nicotine by athletes. While the prevalence of active use was only 15%, the authors noted high prevalence in some sports, included in this table:

Active Nicotine Consumption Among Athletes

Sport (No. of samples)

Active Consumers (%)

American football (19)

56

Basketball (24)

25

Biathlon (38)

18

Bobsleigh (38)

31

Football (soccer) (205)

19

Gymnastics (48)

29

Ice hockey (108)

32

Rugby (25)

28

Skating (41)

20

Skiing (143)

26

Volleyball (46)

20

Wrestling (31)

32

Marclay wrote that these results provide “alarming evidence” about nicotine consumption among athletes. But the report had no information about the athletes who were tested, and the number of samples was minuscule. For example, Marclay’s claim that 56% of American football players actively used nicotine was based on only 19 samples. There are over a million football players at the high school level in the U.S., thousands at the college level, and hundreds in the NFL, and there are 18 other countries with American football leagues. The most alarming aspect of this report is that it made sweeping claims based on very little evidence.

Marclay wrote that “…smokeless tobacco is a very attractive drug from a doping perspective, considering the performance enhancement pharmacological properties of nicotine and the absence of direct adverse effects on the respiratory tract.” Nicotine “exhibits a variety of pharmacological properties sought-after by consumers,” and it “results in vigilance and cognitive function enhancement together with relaxation, reduced stress, mood modulation and lower body weight.”

These effects are well known among tobacco users, but Marclay cited no authority for the claim that these properties enhance performance to an extent that justifies prohibition in sports. In fact, Marclay acknowledged that “the frontier between recreational consumption and use for doping purpose is difficult to ascertain with social drugs, including nicotine, caffeine or tetrahydrocannabinol (THC)[marijuana].” Would Marclay and WADA ban caffeine along with nicotine?

In trying to tie smokeless tobacco to performance enhancement, Marclay offered a startling non-sequitur: “Since smoking may be responsible for noticeable respiratory effects and numerous health threats detrimental to sport practice at top level, likelihood of smokeless tobacco consumption for performance enhancement is a hypothesis of very serious concern.” Simply put: Smoking is very bad, so smokeless tobacco must be a performance enhancer. The association of these two very different products in this manner defies logic.

Marclay was especially concerned about athletes involved in winter sports. Citing his own work (abstract here), he wrote that “a recent study on the 2009 Ice Hockey World Championships brought alarming findings as active nicotine consumption before or/and during the games was highlighted for about half of the athletes.”

If WADA rules eventually that smokeless tobacco and nicotine enhance athletic performance, it will refute tobacco prohibitionists’ persistent claim that tobacco provides no tangible benefits to consumers. As I have written (here), “It’s time to be honest with the 50 million Americans, and hundreds of millions around the world, who use tobacco. The benefits they get from tobacco are very real… It’s time to abandon the myth that tobacco is devoid of benefits, and to focus on how we can help smokers continue to derive those benefits with a safer delivery system.”

Wednesday, October 5, 2011

The British Cabinet Office’s Behavioural Insights Team (BIT), or the “nudge unit”, as the year-old high-level group is called, strongly endorsed tobacco harm reduction in its first annual report (read the report here).

The BIT’s mission is “to find intelligent ways to encourage, support and enable people to make better choices for themselves.” The unit reported that “smoking remains the biggest preventable cause of death in the U.K., killing over 80,000 a year in England alone,” and that “treating smoking-related diseases costs the [National Health Service] £2.7 billion each year in England.”

BIT observed: “A review by the [British] Medicines and Healthcare products Regulatory Agency concludes that ‘nicotine, while addictive, is actually a very safe drug.’ BIT is working with [the U.K. Department of Health] on how to encourage smokers to substitute to safer but nonetheless appealing sources of nicotine, noting that products that produce a fine vapour appear to reproduce the pleasant ‘hit’ without the harms associated with smoking.”

This statement is remarkable. It confirms what I have been reporting for over 17 years: Nicotine, “while addictive, is a very safe drug.” BIT observes that nicotine is a recreational drug that can be used safely, like caffeine and alcohol, and notes that there are efforts to get smokers to substitute “safer but nonetheless appealing sources of nicotine”. E-cigarettes are cited as potentially effective substitutes because of their behavioral attributes.

This positioning by such a high-level entity should significantly advance tobacco harm reduction initiatives on a global scale. U.S. regulatory authorities, in particular, should take note. For the British government, the challenge now is to translate concepts into practical applications. Although e-cigarettes are widely available in the UK, snus and other smoke-free products remain under an EU ban. As awareness of the benefits of tobacco harm reduction increases, British smokers will rightfully demand access to the full range of smoke-free products that are available in Sweden and the U.S.

My Credentials

I am a Professor of Medicine at the University of Louisville, I hold an endowed chair in tobacco harm reduction research, and I am a member of the James Graham Brown Cancer Center at U of L.

For the past 20 years I have been involved in research and policy development regarding tobacco harm reduction (THR). THR advocates acknowledge that there are millions of smokers who are unable or unwilling to quit with conventional cessation methods involving tobacco and nicotine abstinence, and we encourage them to use cigarette substitutes that are far safer.

My research has appeared in a broad range of medical and scientific journals. I have authored commentaries in the general press and I wrote the book, For Smokers Only: How Smokeless Tobacco Can Save Your Life. In 2003 I served as an expert witness at a Congressional hearing on tobacco harm reduction, and I have spoken at numerous international forums, including one held in London at the British Houses of Parliament.

My research is supported by unrestricted grants from tobacco manufacturers to the University of Louisville and by the Kentucky Research Challenge Trust Fund.